Posts About Medicaid and Medicaid Expansion

Yesterday, after three more weeks of backroom deals and secret negotiations, Senate Majority Leader Mitch McConnell unveiled a ‘new’ health care repeal bill that features all the same failings of the previous version. There simply isn’t a tweak big enough that can fix what’s fundamentally wrong with this bill. It still guts Medicaid by more than $2 trillion over the next two decades, forces people to pay more for skimpier coverage and undermines access to services like maternity care or substance use disorders treatment.

Instead of addressing these underlying issues, the latest version of the bill includes a new idea by none other than the Senate’s most famed agitator, Sen. Ted Cruz. Rumors of this amendment swirled for days, and the version that made its way to the bill lives up to the expectations: it’s yet another way to undermine coverage for people with preexisting conditions. By allowing insurance companies to offer bare-bones plans that don’t comply with the Affordable Care Act’s consumer protections – such as the essential health benefits, the ban on coverage denials and cost increases based on health status, and the limits on out-of-pocket costs – this new provision essentially takes us back to the old days of bad insurance practices. This would result in two systems of insurance: one for healthy people and one for those who are sick or have preexisting conditions. It’s a high-risk pool dressed up in new clothes.

During the July 4th recess, members of the Senate, including Sen. Chuck Grassley and Sen. Shelly Moore Capito, publically opposed Cruz’s proposal and at least six others have promised to protect people with preexisting conditions. Conservative groups, the insurance industry and insurance market experts all agree that Cruz’s proposal will destabilize the insurance market and lead to higher costs for people with preexisting conditions. So why isn’t this bill dead on arrival?

Even if Cruz’s proposal ends up in the trash where it belongs, there is still no way to fix this bill. Members of Congress have seen the public polls and they’ve heard it from angry constituents at town halls and jamming their phone lines. It’s time to end the circus and start working on bipartisan solutions that won’t force millions of people to lose their coverage, destabilize the insurance market and irreparably damage the Medicaid program that is a lifeline for low-income families, children and seniors.

This year, many states’ budget negotiations are so challenging that several have made national news: from Alaska with its eleventh-hour showdown to Illinois – which just passed its first budget in over two years – to New Jersey with its closed beaches on July Fourth weekend.  Yet if Congress succeeds in passing its ACA repeal and replace legislation, these state budget negotiations would grow exponentially more challenging.  

Last month, the Congressional Budget Office released its score for the Senate’s Better Care Reconciliation Act (BCRA). CBO found that the proposed legislation would cut $772 billion from Medicaid – slashing its funding by 26 percent in 2026, compared to current projected funding. This alone would blow a hole in state budgets, likely leading states to cut essential programs and services for older adults, people with disabilities and children.

However, that is just the beginning of the bad news. Starting in 2020, the BCRA would cap the federal contribution to states’ Medicaid programs and force it to grow at a rate that is slower than per capita Medicaid costs. In 2025, the Senate’s bill would slow the rate of growth even further. These changes are particularly untenable because Medicaid costs already grow more slowly than those of private health insurance, but still above the rate proposed for 2025 and later.

To make matters worse, CBO’s score only accounted for the bill’s impact during the first ten years after passage. CBO later released an estimate of the bill’s impact during the second decade after passage, which found that by 2036 Medicaid funding would decrease by 35 percent.

Federal Medicaid funds help buoy states’ budgets and economies. For example, Medicaid employs hundreds of thousands of health care workers and provides billions of dollars to schools to ensure all students can fully participate in their education. If these draconian federal funding changes pass into law, states will need to figure out how to make up for the massive loss in the federal contributions proposed under the Senate’s bill.

In effect, these proposed changes to Medicaid financing will trigger a massive ‘race to the bottom’ among the states. Research shows that Medicaid spending varies widely not only among states and between categories, but also within categories. For example, Kaiser Family Foundation found that for children, Oklahoma spent as low as $131 per person up to as high as $24,571 in 2014.

A capped funding proposal will incentivize states to enact policies that increase enrollment by young healthy children and families while decreasing enrollment by older individuals or those with chronic conditions or disabilities. This ‘cherry-picking’ may lead to state policies that are particularly harmful to those who most benefit from access to Medicaid coverage. For example, a state might choose to end programs that place enrollment assisters at safety net hospitals or limit policies that permit presumptive eligibility for children and pregnant people. A state might also make it more difficult for those experiencing substance use issues to access care by limiting payments for mental health services or by decreasing provider payments for specialists.

With massive Medicaid cuts on the horizon, every state has a stake in the decisions Congress will make in the coming weeks. The Senate’s proposed Medicaid financing changes will only exacerbate the challenges states are currently facing as they struggle to balance their budgets.

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

When Ronald Reagan framed unwed, poor mothers of color fraudulently relying on government assistance programs as “welfare queens” during his presidential campaign speeches in 1976, the image of the underserving poor took on a form of Black mothers whose lack was justified – lack of resources, lack of access and lack of equity. Now, as Black women are three to four times more likely to die from pregnancy-related causes than White women, it’s time to drop the deserving versus undeserving poor narrative and work to repair the damage of structural racism meant to deny communities of women equitable rights to have healthy pregnancies and families when they choose to.

Storytelling in health advocacy is often a useful approach to give stakeholders, policy makers and other advocates an image of a policy initiative’s impact. These narratives apply a much-needed human aspect to what otherwise could be lost in data and numbers by sharing a human experience and generating social sympathy. But what happens when narratives turn negative, relying on racism, sexism and classism to paint a picture of the deserving and underserving of health resources and social services – especially of black women who are now at most risk for poor maternal health outcomes?

Currently, Black maternal mortality is not just a problem among those with a low socioeconomic status. In fact, the birth outcomes disparities between Black women and White women show similar poor outcomes across all income and education levels, suggesting a direct link to racism further supported by racist narratives.  Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age.” They include factors like socioeconomic status, education, the physical environment, employment  and social support networks, as well as access to health care. Through policies and programs within the social determinants of health, racist narratives create barriers and can impact how women access health coverage, quality care, employment and other resources to achieve optimal health. Using theories like Critical Race Theory  to analyze how racist narratives permeate into policy and programs can help shift view and ultimately outcomes. By rejecting a tradition of meritocracy, the false picture that everyone who works hard can attain wealth, power and privilege is denied and instead we can recognize the impact that systemic inequities have on the marginalization of people of color.

Last month, the Black Mamas Matter Alliance (BMMA) held their first briefing on Capitol Hill to highlight their work and build a supporter base around the alarming rates of black maternal mortality in the United States. Led by Black women, including Community Catalyst board member Dr. Joia Crear-Perry, BMMA is a cross-sectoral alliance that centers Black mamas to advocate, drive research, build power and shift culture for Black maternal health, rights and justice. Through their work, BMMA purports that all women have the right to safe and respectful health care that supports healthy pregnancies and births. These rights mean that before, during and after pregnancy, every woman needs access to quality health services and information, to the social and economic resources that will help her be as healthy as she can.

Critical to black maternal health is our current advocacy campaign to save Medicaid and the Affordable Care Act for children and families. Now is the time when we have to eliminate the racist narrative of the “welfare queen.” Our stories must center around addressing racial discrimination and structural racism by recognizing it. By shedding light on the harmful outcomes of health inequities, we can share multiple narratives. We must also continue to frame our message using a two generational approach meaning that a family’s access to health care cannot be siloed. Healthy parents – mothers and fathers – are able to care for their children, helping ensure that they thrive and become healthy adults. Specifically, when mothers die, it breaks apart families and can lead to negative health consequences for their children. We must trust Black women with the decisions and resources that empower them and their families. We must trust black women to tell their own dynamic stories and shape the narratives that reflect their realities. In her TED Talk, novelist Chimamanda Ngozi Adichie shared, “The problem with stereotypes is …that they are incomplete. They make one story become the only story.”

The Senate yesterday delayed its plan to vote on its health care repeal bill, also known as the Better Care Reconciliation Act of 2017 (BCRA). On Monday, the Congressional Budget Office (CBO) released its score of the bill and projected it would cause 22 million individuals to be uninsured by 2026, including 15 million individuals enrolled in Medicaid. The bill effectively ends the Medicaid expansion program and cuts $772 billion in Medicaid funding. Senate Republicans offer two options to current expansion enrollees: 1) prohibitively expensive coverage, or 2) no coverage at all.

Spending half their annual income on health care is not a viable option for low-income families

Republican Senators were quick to tout that current Medicaid expansion enrollees still had coverage options under the bill because it expands the eligibility for tax credits to the expansion population (i.e., from 100-400 percent of the Federal Poverty Level (FPL) under the Affordable Care Act (ACA) to 0-350 percent FPL). Senator Richard Burr of North Carolina touted that the bill “better targets tax credits to low-income individuals.”

But the bill’s replacement of Medicaid with private coverage is not a viable alternative for this population. First, the bill cuts tax credit funding by $408 billion, and therefore while it attempts to provide credits to more low-income individuals, there will be substantially less funding to go around. Second, the bill changes the tax credit eligibility rules to prohibit anyone with an offer of employer-sponsored insurance (ESI) to be ineligible for tax credits, regardless of how much that ESI would cost. But Medicaid expansion enrollees’ incomes are so low, that almost any offer of ESI would be prohibitively expensive for them. Yet, under the Senate bill, that coverage would be their only option.

In addition, the Senate bill ties tax credits to plans with far higher out-of-pocket costs, which will make coverage prohibitively expensive for many, particularly those between 0-100 percent FPL. Specifically, the bill changes the “benchmark plan” on which premium tax credit calculations are based from the ACA’s “silver-level” plan – a plan that covers 70 percent of the costs of the standard population – to a plan that only covers 58 percent of such costs, leaving enrollees with significantly higher out-of-pocket costs. The CBO estimates that moving the benchmark plan to a 58 percent Actuarial Value plan would lead to deductibles that would represent a “significantly higher percentage of income” than under the ACA, and individuals at 75 percent FPL would be required to spend more than half of their income on their deductible. As a result,” the CBO concludes, “few low-income people would purchase any plan.”

Unaffordable coverage options will lead to spikes in uncompensated care

If the current Medicaid expansion population chooses not take up either of these highly problematic options, there will likely be a spike in uncompensated care costs that providers and states will have to absorb. Research has shown that states that expanded their Medicaid programs saw significant reductions in their uncompensated care costs, but these reductions will likely reverse under the bill. Instead, left only with the options of employer-sponsored coverage or marketplace coverage, many Medicaid expansion enrollees may simply choose not to enroll in coverage, as the CBO expects, and instead seek care at safety-net providers. And many who do enroll will be burdened with medical debt when they seek care, since they will not be able to afford their deductibles.

Overall, to provide affordable coverage options to low-income individuals, the Senate needs to reverse course entirely. Right now, the basic structure of bill is tax cuts for the rich financed by benefit cuts for low- and moderate-income families. Unless that underlying structure is changed, it’s clear that Medicaid expansion enrollees will be left behind.

By now, you’ve already seen the key takeaways from the Congressional Budget Office (CBO) score of the Senate repeal bill. But what you might not know is that the CBO score hides the most devastating of the Senate bill’s effects. Indeed, the CBO score only shows the tip of the blade that will continue to slash into Medicaid for decades to come.

According to the CBO’s analysis released yesterday, over the period of 2017-2026, the Senate’s repeal bill would:

  • Cause 22 million people to lose their health care coverage by 2026
  • Cut $772 billion from Medicaid – slashing its funding by 26 percent, and blowing a hole in state budgets which would likely lead states to cut essential programs and services for seniors, people with disabilities and children.
  • Slash the subsidies available to low- and moderate-income families by $408 billion, and leave families exposed to far higher out-of-pocket costs.
  • Eliminate the Medicaid expansion that covered millions and replace it with private coverage that the CBO says would become so expensive they would not be able to afford it. For example, a person earning $11,400 would face a deductible of more than half their annual income.
  • Lead close to half the population to lose access to critical services, such as maternity care and treatment for substance use disorders
  • All this, just to finance tax cuts for the wealthy.

But the CBO score hides the worst of the Medicaid cuts, because its projections stop in 2026 - just as the Medicaid cuts begin to sink even deeper.

Starting in 2020, the Senate bill would cap the federal contribution to states’ Medicaid programs and would force it to grow at a rate that is slower than per capita Medicaid costs (the Consumer Price Index – Medical (CPI-M) inflator for most enrollees and CPI-M plus 1 percentage point for disabled adults or age 65 or older.) Since CBO projects per capita costs of non-disabled children and adults to rise at 4.9% - but CPI-M will only be 3.7% – this change alone would result in significant reductions in states’ Medicaid funds.

But starting in 2025 – at the very end of the CBO score’s time period – the Senate bill would make far deeper cuts in Medicaid by dramatically slowing the growth of the per capita caps for all enrollees to Consumer Price Index for all urban consumers (CPI-U). The CBO projects CPI-U to grow only at 2.4% annually over this time period, while costs of non-disabled children and adults will rise at more than twice that rate.

This shift would push dramatically more costs onto states, but conveniently (for the Senate GOP leadership) it is barely captured at the tail end of the CBO’s 10-year score window. And it exemplifies how converting Medicaid into a capped funding program merely creates a dial that Congress could ratchet up for additional savings every time it needs to pay for another priority. (We already saw this in the Trump budget where they sought to add hundreds of billions of dollars in cuts on top of those that were in the House's version of ACA repeal.)

This massive cost-shift to states would only grow year after year. It would force states to eliminate life-saving services for children with special health care needs. It would deprive people living with disabilities of the services they need to live independently and it would shift new costs onto family budgets as they struggle to find ways to balance the health and long-term care needs of aging parents against other demands.

After reviewing the Senate repeal bill, the National Association of Medicaid Directors concluded, "No amount of administrative or regulatory flexibility can compensate for the federal spending reductions that would occur as a result of this bill." So as scary as the CBO score is, remember this: the worst would be yet to come.

Even close readers of the news can be forgiven for not understanding how perilously close the Senate is to not only ripping coverage away from millions of people, but also cutting Medicaid funding for children, seniors and people with disabilities and putting a vice around the program. After all, there continue to be multiple conflicting reports relating to the content, timing and degree of agreement among Republican senators. So, without further ado, your handy guide to what we know and don't know about where things stand in the Senate.

More like the House bill than not

Despite all the denials and claims that they are starting over, the House bill will provide the basic architecture of what the Senate does. It is not the case that the Senate will bring the House bill to the floor and then replace it with a substitute that looks much different. The key elements of the House bill – eliminating the Medicaid expansion, capping federal Medicaid funds to states, slashing tax credits and cost-sharing assistance in a way that particularly harms lower-income and older people, undermining insurance market protections for people with preexisting conditions, and big tax cuts for the rich and for insurance companies and the drug industry – will all likely be retained in the Senate proposal.

Less opposition than you might think

There is more support in the GOP Senate caucus for this "basket of deplorables" than people may realize based on senators’ public statements. In particular, it would be a mistake to conclude that members who have expressed skepticism that the Senate will pass a bill will themselves ultimately be a “no” vote. Everyone is still leaving themselves with a lot of wiggle room, and many of the most vocal Senate critics of the House proposal have begun making positive noises about the Senate bill, even though it will be very similar (Senator Cassidy, a case in point).

Sooner rather than later

The issue is coming to a head sooner rather than later – McConnell wants to get off of health care and move on to other matters like reforming the tax code. We are expecting a Senate vote before the July recess begins on June 30, though it is not impossible that it could slip until immediately after the recess. That doesn't mean the Senate Majority Leader will just throw a bill out there and figure “if it fails, it fails.” The public comments following the Republican caucus last week suggest that he is making headway toward getting the 50 votes he needs.

Don't expect to see the bill in advance

The exact contours of the Senate proposal will be kept from the public (and the members) until the very last minute. While the situation is serious, some important decisions and significant fault lines remain, including:

  • Medicaid: With respect to Medicaid, the timing of the phaseout of the expansion remains uncertain. A number of senators are on record in support of a seven-year phaseout of enhanced federal match. While the disastrous end results would be the same, there appears to be a sense among the "moderates" that a slower phaseout provides better optics and ideally – from their point of view – delays the worst consequences of the bill until after their next reelection bid, whether that falls in 2018, 2020 or 2022.
  • Per Capita Cap Growth Rate and Base Year: There has been an ongoing debate between senators who want to keep or improve on the growth rate in the House bill and those who want to cut Medicaid spending even more than the $839 billion in AHCA. There have been rumors of a trade between a lower growth rate and a longer phaseout of the expansion, but at this point those remain rumors. Meanwhile, both the growth rate and the base year of the cap have emerged as potential flash points. Some senators from low-spending states have voiced concerns about being unfairly locked into lower federal reimbursement rates in perpetuity.
  • Tax Credits: The Senate will try to add some money back to the House proposal to soften the blow on lower-income and older adults, but they are unlikely to have enough money to prevent a massive drop off in insurance coverage. The question is whether that will deter any senators from voting for the bill and whether we will even know the CBO estimate of the effect on coverage before the Senate votes.
  • Tax Cuts: Expect the Senate proposal to mirror the House but with delayed effective dates to help pay for the slower phaseout of the Medicaid expansion and for adding money to the tax credits.
  • Consumer Protections: The provision allowing states to let insurers charge people more if they are sick or "high risk" will likely fall out, but state waivers of Essential Health Benefits at this point appear likely to stay in. With dramatically lower premium support, states will be under pressure to cut down the benefit package whether they want to or not. The result will be a big spike in out-of-pocket costs, particularly for people with serious and expensive health conditions.

While the Senate is trying to speed toward the floor, some process challenges remain that have not been fully worked through. Three are worth keeping an eye on:

1. Cost Sharing and the Indian Health Service

Democrats are arguing that the provision of the law that eliminates cost-sharing assistance touches on the jurisdiction of the Indian Affairs Committee. Since that committee did not receive reconciliation instructions, sending the bill over to the Senate as-is could remove the protection of the reconciliation process and subject the bill to a 60-vote requirement, under which it would certainly fail. To avoid this, the House would have to amend the bill before it is formally transmitted to the Senate.

2. Allocation of Savings

In order to comply with the reconciliation instructions, which are what enable the bill to move forward with a simple majority, both the HELP and Finance committees must identify at least $1 billion in savings. Senate Budget Committee Chair Enzi has asserted both that the bill meets that test and that he is the arbiter of whether it does or doesn't. Ranking minority member Sanders is arguing that the bill fails the test and that the Parliamentarian must make a ruling.

3. Abortion

The House bill prohibits tax credits from being used for plans that cover abortion. This could run afoul of the Byrd rule, which requires provisions in a reconciliation bill to have a more-than-incidental effect on the budget. If the language is stricken, anti-choice legislators in either the Senate or House could withdraw their support from the tax-credit provisions entirely, which could sink the bill.

Even as more moderate members have indicated that they are encouraged, the most reactionary members are starting to voice concern and displeasure. Since McConnell can’t afford to lose three votes in the Senate, opposition from Senators Paul, Lee and Cruz, among others, could sink the bill.

With all of the uncertainty swirling around, McConnell still has two main paths to getting a bill through the Senate (and ultimately to final passage). First, he could get all the moderates on board while losing only two from the far right. Then, back on the House side, if some Freedom Caucus members flip to “no,” their votes could be offset by House members who voted “no” on AHCA in May but now could hide behind the largely cosmetic changes in the Senate: this could allow the Republicans to eke out a narrow victory. In the alternative, McConnell could follow the path of the House, appease the far right and dare the shaky moderates to vote “no.”

One thing we do know for sure: Unless the GOP skeptics of the House bill face an outpouring of resistance in the next few weeks, we are likely to see not only a rollback of the progress made since 2009 but also a fundamental undermining of the health care safety net that has been in place since 1965. That ought to make America great again.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.

If there is any takeaway from the double threat the AHCA, as reassessed by the CBO last week, and the Trump budget, which was also released last week, pose to our health and economic security, it is that it is vitally important to keep our eyes on what the people running the government in Washington actually do while regarding their words with extreme skepticism.

In the wake of both developments last week, we were treated to so many breathtaking whoppers that it is hard to know where to begin. If there were an award for double-speak, there would be a rich candidate pool from which to draw. Below are a few potential award winners.

Consider the double dishonesty of Paul Ryan, who continues to characterize his efforts to save the Affordable Care Act (ACA) insurance markets by destroying them as an act of compassion. Ryan continues to tout CBO's finding that in the long run, premiums would go down under the AHCA. But he ignore the fact that the decrease in average premiums stems from a combination of increased out-of-pocket costs and excluding older and sicker people from coverage entirely. Furthermore, as the CBO analysis illustrates, not only would the AHCA undermine consumer protections and slash tax credits that make coverage affordable, but under the false flag of saving us from the ACA, it would fulfill Speaker Ryan's lifelong dream of taking healthcare away from seniors, people with disabilities and low income children and families. The AHCA makes steep cuts both to the part of Medicaid the ACA expanded and the core program that has protected vulnerable populations for the last 50 years.

Or consider three health care promises of Donald Trump: not to cut Medicaid, to protect people with preexisting conditions and to make affordable coverage available to everyone, The CBO analysis and Trump’s own budget exposed these promises as lies last week (some, not for the first time). (He also promised not to cut Medicare or Social Security and has proposed or supported cuts in both of those programs.) To understand the dystopian future of health care the Trump administration envisions, you really have to read the budget proposal and AHCA together. AHCA has not even moved from the House to the Senate, and the administration is already doubling down on the cuts to Medicaid. While it is difficult to tease out exactly what the budget proposes, the reduction in federal funds to Medicaid could climb to as much as 45 percent within 10 years.

While we're discussing the Trump budget, consider the sophistry of OMB Director Mick Mulvaney -- having a Mitt Romney moment -- who advanced the bogus distinction between taxpayers and recipients of health care benefits. Mulvaney conveniently ignored the fact that the people who receive coverage via the ACA, Medicaid and Medicare all pay taxes and the millions of people with employer-sponsored insurance enjoy a large tax subsidy.

And how are we to understand the words of Freedom Caucus co-chair Mark Meadows -- who got choked up as recalled his family's struggles with illness and claimed that those experiences had sensitized him to the problems of people with people with pre-existing conditions?  Are we to believe that he really didn't know how the bill he helped shape and push through the House would affect people with pre-existing conditions? Perhaps he should be taken literally, after all, he said he was not going to make a political decision on May 24th to take health care away from sick people. Technically that was a true statement, since he had made that decision weeks earlier when he voted to pass AHCA.

Finally, consider the words of Senate Majority leader Mitch McConnell who last week said, "I don't know how we are going to get to 50 in the Senate." A true statement, and different in nature than the others, but still easily misinterpreted. It would be as dangerous to read too much into McConnell's seemingly innocuous statement as it would be to take the others’ statements at face value. Doing so could lull people into a false sense of security. Just because at this moment McConnell does not know the path to 50 votes or the content of a Senate bill should not be interpreted to mean that the Senate will not do a bill or that they will do a bill that departs drastically from the House proposal.

Although many Senators have voiced concerns about the House bill, we can no more rely on the "reasonableness" of the Senate than on the false words of Trump, Ryan and company. Remember, any lurch toward reason in the Senate runs smack into the prime directive of the modern GOP: that the solution to any problem is always a tax cut for the rich. Further, a bill in the Senate must reduce the deficit by the same amount as the House bill (now pegged at $119 billion by CBO). The combination of the deficit reduction target and the Republican Party's commitment to big tax cuts for the rich spells big trouble for people with disabilities and preexisting conditions and for people of modest income who lack employer-sponsored insurance.

The only hope to avoid turning back the clock not only on the ACA, but also on Medicaid, is a massive show of resistance. This needs to start this week when Senators are home for recess and continue until they abandon their mad project of undermining the health and economic security of millions of people.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.

This blog is part of a series that will highlight how structural racism in the health care system negatively affects the health of individuals of color. Community Catalyst is committed to exposing and dismantling policies, practices and attitudes that routinely produce cumulative and chronic adverse outcomes for people of color in the health system.

The American Health Care Act (AHCA), as passed by the House of Representatives and sent on to the Senate, would make draconian cuts to Medicaid funding and reduce the federal minimum eligibility level for children ages six to 19 from the current 138 percent, to 100 percent, of the federal poverty level. That translates to an income of $20,420 or less for a family of three. These changes would reverse the progress on children’s coverage that has been made through the ACA and dramatically undermine critical services for children and families across the country, especially low-income children and children with special needs. Data continues to emerge as to how terrible this bill is – from estimates on the burden it would place on state budgets to the financial impact on schools that provide health services to children enrolled in Medicaid, resulting in reduced access to care, especially for children with disabilities. The Congressional Budget Office’s newly-released estimates confirm both the financial losses for states and the human impact of the AHCA—14 million could potentially lose their access to Medicaid by 2026.  

Today, in a new report, the Institute for Child, Youth and Family Policy at Brandeis University – explores the racial and ethnic breakdown of these potential coverage losses for children. The results are stunning for Black and Hispanic children across the country.

The fate of the House bill now rests with the Senate.



What does the data show?

Both the actual number, and disproportionately high share, of coverage losses for Hispanic and Black children is significant nationwide, with some of the greatest impacts concentrated in Southern states. The table below shows the top ten states facing a decline in number of children that meet the federal eligibility minimum:

California, Texas, Florida and Georgia are among the states with the largest declines in the number of children eligible for Medicaid under the House version of the AHCA, ranging from 462,500 Hispanic children in California to 88,200 Black children in Florida (Table 2). Looking at these numbers expressed as the percentage of children of color in a given state who would lose access to their current Medicaid coverage paints the threat more starkly. Tennessee would be the state with the largest decline in the percent of Hispanic children federally eligible for Medicaid under the AHCA proposal, with a 20.4 percentage point decline, followed by Wisconsin at 19 percent. For Black children, Utah and Kansas rank first and second in their percentage point decline in children federally eligible for Medicaid, at 17.3 percent and 15.9 percent, respectively.

What do these numbers mean?

The GOP bill, now being worked on behind closed doors and without public hearings in the Senate, reverses the impressive coverage achievements made possible by the partnering of the ACA, Medicaid and CHIP. For children of color, the impact could not be clearer: hundreds of thousands of children of color stand to lose access to vital health care helping them thrive, made possible by their Medicaid coverage. This is close to 10 percent of the school-aged population – about 5 million children. School-aged children’s loss of coverage is particularly troublesome because of Medicaid’s Early Periodic Screening Diagnosis & Treatment (EPSDT) benefit that ensures access to critical preventive services and care. In sum, this step backwards for our country would explicitly and disproportionately harm children of color in the near-term and exacerbate troubling long-term health inequities across our country that many of the ACA’s provisions have just started to address. 

What can advocates do?

Advocates can take a dive into their own state-level data to understand the health equity impact of the school-aged proposed rollback. Learn more about your state here. Amplify the data and tell the personal stories of children in your state. Be specific about which racial and ethnic groups will suffer and could lose access to important preventive services because of AHCA. Effective storytellers can include teachers, school nurses, caregivers, providers, parents and youth. Policy makers need to hear from us to help them fully understand how their actions on this dreadful piece of legislation will determine the future of progress on health equity in the United States.

Despite his repeated promises on the campaign trail that he would not cut Medicaid, President Trump’s FY 2018 budget would slash the program’s budget nearly in half over the next decade. The budget assumes the $839 billion in Medicaid cuts in the American Health Care Act (AHCA) become law, and then calls for an additional $627 billion in cuts to the program, all while slashing other safety net programs too.

An attack on health and economic security for low-income communities

Cuts of this magnitude would put at risk the health of the millions of older adults, people with disabilities, children and low-income families who depend on Medicaid for their care. They would undermine a program that is essential to the fight against the opioid epidemic. And they would rock the economic security of low-income communities, who depend on Medicaid coverage to protect them against crippling medical debt.

What’s more, the Trump budget pairs these Medicaid cuts with deep cuts to other essential health and social welfare programs - like food stamps and disability insurance. Together, these programs not only boost economic security for low-income families, they also contribute to health security by putting healthy foods and safe housing within reach of families who could not otherwise afford them. By slashing these programs alongside Medicaid, the Trump budget is an all-out attack on the health and economic security of vulnerable communities.

A wakeup call for America’s governors

While many governors have expressed concern about how the AHCA ends the enhanced funding for the ACA’s Medicaid expansion, they have said relatively little about how it also turns Medicaid into a per capita cap. This budget should be a wake-up call for those governors: per capita caps are a Trojan horse that will allow the federal government to balance its budget at the expense of state budgets.  

While budget documents don’t make it entirely clear how the administration would achieve over $600 billion additional savings in Medicaid, Trump’s budget director Mick Mulvaney explained that the additional funding cuts result from a reduction to the growth rate for the per-capita cap, compared to the AHCA. That’s just a backdoor way of shifting Medicaid costs from the federal government on to states.

The Trump budget exposes as wishful thinking any assumptions that governors may have made that they could weather the AHCA’s cuts to Medicaid by utilizing additional “flexibility”. The AHCA doesn’t merely make $839 billion in Medicaid cuts; it creates a dial that Congress and the administration can and will ratchet down any time they want additional savings. The $1.47 trillion in Medicaid cuts inherent in Trump’s budget this year is likely just the beginning.

Additional cuts targeted at children

Trump’s budget also targets the Children’s Health Insurance Program (CHIP), which provides health insurance to children of low- and moderate-income families who are not eligible for Medicaid. In 2016, CHIP covered nearly 8.9 million kids, while Medicaid covered about 37 million. Together with Medicaid, CHIP coverage has helped lower the uninsurance rate for children to a historic low of 4.8 percent.

CHIP is currently funded through September 30, 2017 but will need another funding extension in order to continue past that date. The Trump administration’s proposed budget would extend CHIP funding for only two years despite the recommendation from the Medicaid and CHIP Payment and Access Commission to extend funding for five years.

The proposed budget would end the higher federal CHIP matching rate known as the 23 percent bump and eliminate the Affordable Care Act’s Maintenance of Effort requirement at the end of September—two years earlier than the ACA intended. It also assumes the AHCA provision that rolls back eligibility for school-aged children from 138 percent FPL to 100 percent FPL—potentially affecting millions of children. We know that Medicaid and CHIP disproportionately cover children of color, so not only is this a loss in coverage but a step backward in our efforts to address health equity.

Trump’s budget would further undermine CHIP’s efficacy by eliminating federal enhanced matching funds to children above 250 percent of the Federal Poverty Level. This is particularly problematic because in many states CHIP eligibility extends beyond this marker. For example, Alabama provides CHIP coverage up to 317% FPL and New York goes up to 405% FPL. By capping these CHIP eligibility levels, the Trump budget reduces state flexibility in meeting the needs of children. Overall, the Trump administration’s budget does not help advance children’s health, instead it puts us in danger of reversing our hard won coverage gains.

It’s May, and that means it’s Older Americans Month. This year’s theme is Age Out Loud, chosen “…to give aging a new voice – one that reflects what today’s older adults have to say.”

Older Americans are a group that have a lot at stake in ongoing health system transformation initiatives. A vital goal of the Center for Consumer Engagement in Health Innovation is promoting the meaningful role older consumers can exercise when they lift up their voices. Several of our staff members recently met an older adult who perfectly exemplifies what it means to stand up and speak out loudly for better health out of one’s own life experience. Kathy Paul is a 69-year-old resident of Lynn, Massachusetts and an active member of the Massachusetts Senior Action Council. The Council, founded in 1981, is a statewide, grassroots, senior-led organization that empowers its members to use their own voices to address key public policy and community issues that affect their health and well-being.

Kathy spoke out loudly at a press conference in Boston on May 8 [video courtesy of BNN – Boston Neighborhood Network] on the American Health Care Act, a bill that would result in significant cuts to care for older adults. The bill was passed by the U.S. House of Representatives and is now pending before the Senate. Kathy joined Sen. Edward Markey and other community leaders at the event, including speakers from Health Care For All, Community Catalyst, Health Law Advocates, Boston Medical Center GROW Clinic, Disability Advocates Advancing Our Healthcare Rights, Massachusetts Senior Action Council, Massachusetts Organization for Addiction Recovery, the American Cancer Society Action Network and the American Heart Association.

Kathy introduced herself “…not just as an activist, but as a mother of five, a grandmother of 10, and a great-grandmother of five, who is deeply concerned about the future of health care.”

She continued: “As a senior, I live on a very limited fixed income and I rely on MassHealth [the Massachusetts Medicaid program] for my health care. I feel very fortunate because, for the most part, I am very healthy. I don't take any medication and stay very active. But I know the reality of when that's not the case. My husband had several very serious health conditions including diabetes and kidney failure. He had to endure two amputations below the knee and was on dialysis three times a week. If it was not for MassHealth, we would never have been able to cover his care. I am thankful that I was able to focus on taking care of him rather than worrying about how we would pay for the care he needed or being denied because we did not have the money to meet a huge deductibleThis debate is not about party politics. This debate is about the wealthy getting wealthier and the rest of us paying the price. We cannot allow this assault on our right to basic health care to move forward. We must speak up and speak out.”

Kathy first got involved with the Massachusetts Senior Action Council in 2007, while her late husband was still alive and she was putting most of her energy into the demands of caring for him. After he passed away in 2012, it was a turning point in her life. She explains, “With more time on your hands, what do you do? Just sit in the house, stare at the walls and complain, or get out and do something about it? What our group likes to say, ‘we don’t just take it, we take charge!’”

In recent years, ‘taking charge’ for Kathy has meant testifying at the Massachusetts Statehouse against rate hikes for older adults using public transportation services and advocating for genuinely affordable housing options for older adults in the Commonwealth. And on a Monday morning in May, it meant joining hands with her United States senator and telling her story from the podium to a bank of television cameras and assembled reporters.

We can’t wait to see what she’ll do next.

During this month, let us know at @ccehi how you #AgeOutLoud!

With our thanks to Kathy Paul for her guest contributions to this post.

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